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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468 -3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi es. <br /> Job Address City a66 Lot Size/Acreage <br /> ' Phone 9/(fl'®j�9"f <br /> n 's Nam ' 0]4 one, <br /> rector _^�� S se No, <br /> TYPE OF WELL/PUMP: NEW'VAL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER p Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack7 D Tracy Type of Casing_ Specifications <br /> I"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .J/ Approx. De th I E tern 1 rf urface Seal Installed by <br /> Repair Work Done De Type of Pump / H,P. f �� _— State Work Don <br /> Well Destruction 0 Well �aqe ! Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I k INo septic system permitted it public sewer is <br /> available within 200 fest.f <br /> Installation will serve: Residence— Commercial_ Other f <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: . Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application an'd-that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cati la." <br /> The applican us call forAr inspections. Complete drawing on rev se side. <br /> Sign Title: Date: <br /> D DEPARTMENT USE ONLY <br /> Application Accepted by Date Z! Area { <br /> Pit or Grout Inspection by Date Final Inspection byDate 0/1/f 21 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> (INFO <br /> : EK 1344(REV.I y A 6) �/ a. . �� � / � � � w <br /> EH 14.26 1 Li5 <br />